RN Case Manager facilitating transitions for patients from LTAC to lower levels of care. Engaging with interdisciplinary teams to ensure continuity and compliance throughout the process.
Responsibilities
Facilitate safe, timely, and well-coordinated transitions of patients
Attend scheduled onsite days at assigned LTAC facilities
Participate in interdisciplinary rounds and discharge planning meetings
Review provider discharge readiness decisions and ensure orders are initiated promptly
Identify barriers to discharge and escalate as necessary
Support family and caregiver education on post-discharge instructions
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